Videos can help cancer patients choose level of care they prefer

Patients with terminal brain cancer
who watched a brief video illustrating options for end-of-life care were
significantly more likely to indicate a preference for comfort measures only
than were patients who listened to a verbal description of treatment
choices. Practically all those viewing
the video would choose not to receive cardiopulmonary resuscitation (CPR) after
their cancer became advanced, compared with only half of those in the control
group, report the authors of a study that will be published in the Journal of Clinical Oncology and has
received early online release.

"Advanced care planning is
challenging for both patients and physicians, probably because of difficulties
with physician/patient communication and patients' limited knowledge about what
the various levels of care really involve," says Angelo Volandes, MD, MPH, of
the Massachusetts General Hospital (MGH) Department of Medicine, corresponding
author of the Journal of Clinical
Oncology article. "We previously studied
whether video could help healthy elderly patients plan end-of-life care if they
developed dementia, and as far as we know this is the first investigation of video
as part of advanced care planning for cancer patients."

The research team enrolled 50
patients treated at the MGH
Cancer Center
for malignant glioma, the most common
and deadly form of brain tumor. Upon entering
the study, participants were asked a series of questions assessing their
knowledge about advanced treatment measures - including the likely results of
CPR or ventilator care - and whether they would choose to receive CPR after
their cancer had reached an advanced stage.

Participants were then randomly
assigned to either listen to a verbal description of three levels of care -
life-prolonging care, including CPR and mechanical ventilation; basic hospital
care, including the use of antibiotics and intravenous fluids; or comfort care
only - or to view a 6-minute video illustrating those levels of care after
listening to the same verbal narrative.
The video depicted life-prolonging care with scenes of a simulated CPR
administration and a ventilated patient in an intensive care unit; basic care was
illustrated with hospitalized patients receiving treatments such as intravenous
antibiotics; and comfort care showed patients receiving food, oxygen therapy
and other comfort measures at home or in a hospice.

After either intervention,
participants were again asked which level of care they would prefer when their
cancer became advanced and whether they would choose to receive CPR. They were asked the knowledge assessment
questions again and also took a standard assessment of how certain they were of
their decisions. Those who viewed the
video were asked about their reactions to what they had seen.

Among the 23 participants who
viewed the video, 21 indicated a preference for receiving comfort care
only. One chose basic care, one was
undecided, but none chose life-prolonging care.
About half of the narrative-only group - 14 of 27 participants - chose
basic care, with six choosing comfort care and seven choosing life-prolonging
care. Preferences regarding CPR had been
almost the same before the intervention - with half indicating no, a third
indicating yes and the rest uncertain - but when reinterviewed, all but two of
those viewing the video said they would not choose CPR, while preferences among
the control group were largely unchanged.

"In addition to being much more
likely to prefer comfort-oriented care, those who viewed the video were
overwhelmingly comfortable watching it and found it to be helpful and something
they would recommend to other patients. They were also more certain of their
decision and more knowledgeable about their options than control group members,"
says Volandes, an instructor in Medicine at Harvard Medical
School.

"These results show how videos can
help surmount communication barriers and reinforce patient/doctor discussions
to solidify patients' choices for their medical care," he adds. "We are continuing to explore the role of
video in advanced care planning for a more diverse group of patients with
different forms of cancer." More
information on this project is available at http://www.ACPdecisions.org.

The first author of the Journal of Clinical Oncology report is Areej
El-Jawahri, MD, MGH Department of Medicine.
Additional co-authors are April Eichler, MD, Scott Plotkin, MD, and
Jennifer Temel, MD, MGH Cancer Center; Yuchiao Chang, PhD, and Michael Barry,
MD, MGH Medicine; Lisa Podgurski, MD, University of Pittsburgh Medical Center;
and Susan Mitchell, MD, Hebrew Senior Life, Boston. The study was supported by
grants from the Foundation for Informed Medical Decision Making and the
National Institutes of Health.

Massachusetts
General Hospital,
established in 1811, is the original and largest teaching hospital of Harvard Medical School.
The MGH conducts the largest hospital-based research program in the United States,
with an annual research budget of more than $600 million and major research
centers in AIDS, cardiovascular research, cancer, computational and integrative
biology, cutaneous biology, human genetics, medical imaging, neurodegenerative
disorders, regenerative medicine, systems biology, transplantation biology and
photomedicine.